Documentation Requirements for Prior Authorization of an Elective Lumbar Fusion

WSI has recently received an increase in incomplete prior authorization requests for elective lumbar fusion surgeries. For services requiring prior authorization, WSI’s UR department utilizes Official Disability Guidelines (ODG) as the standard of care. A provider must submit documentation of the following pre-operative clinical surgical indications, as outlined by ODG:

• Documented failure of conservative care
• Imaging reveals spinal instability, or nerve root impingement correlated with symptoms and exam findings
• Recommended levels of fusion, not to exceed two
• Psychosocial screen completed, with confounding issues addressed
• Cotinine screening completed with negative result at six weeks and one week prior to scheduled surgery date
• Patient awareness of alternative treatment options, risks and benefits of the procedure

For additional information on WSI requirements for the approval of an elective lumbar fusion, a provider should refer to the Lumbar Fusion Guidelines.

If you have questions about this article, please send an email to wsipr@nd.gov.  To receive provider news, subscribe to our Email Updates list.